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Ten essential health benefits

Starting in 2014, The Affordable Care Act requires health-insurance plans, both individual and small-group coverage, to provide essential benefits in at least ten categories. In order to be certified and offered through healthplanfinder, all policies must cover services in the following categories:

Ambulatory care. This coverage applies to advanced medical treatments, generally in a hospital setting, that are performed on an outpatient basis. These services include diagnostic procedures such as x-rays, blood tests, MRI’s and biopsies, as well as minor surgeries in which the patient registers and is discharged within the same calendar day.

Emergency services. As the term states, these services apply to response and treatment of acute conditions that require immediate care. Coverage includes on-site stabilization care, ambulance services and emergency-room treatment.

Hospitalization. In-patient coverage kicks in when a hospital stay extends beyond a calendar day. Hospitalization is far and away the most expensive setting of care delivery. Plans can vary widely in coverage levels. The best policy options depend heavily upon life stage and any existing conditions.

Maternity and newborn care. This coverage applies to minimum length of hospital care for mother and newborn(s). The requirements specified in the Newborns’ & Mothers’ Health Protection Act of 1996 will be required of all individual and small-group plans. Natural childbirth stays can be limited to no less than 48 hours and cesarean deliveries to no less than 96 hours; though discharge can be earlier if patient and doctor agree.

Mental-health and substance-abuse treatment. Starting 2014, an estimated 32 million Americans will gain access to these vital “whole-person” services. Coverage for identified behavioral disorders and substance abuse will be treated the same way as coverage for medical disorders. These services include one-on-one sessions as well as group and community treatment settings.

Prescription drugs. Most plans currently include options for medication co-pays. All policies to take effect in 2014 will have to include provisions for coverage of prescription drugs. For those on multiple prescriptions, especially seniors, this coverage can be particularly crucial.

Rehabilitative and habilitative services and devices. Rehabilitative services are those that help patients to regain full or partial functioning and improve daily living skills lost or impaired due to injury or illness. Habilitative services refer to those that help patients, particularly children, learn and improve daily living skills, such as a child experiencing difficulty walking or talking at the expected age. Services for both rehabilitative and habilitative care include physical and occupational therapy, speech-language pathology and psychiatric rehabilitative services in both inpatient and outpatient settings. Devices may include braces, walkers and prosthetic limbs.

Laboratory services. Lab services are typically covered under current policies, and must be covered under the new act. These services relate to analysis of bodily fluids, particularly blood and biopsy tissue for disease and other factors.

Wellness and chronic disease management. The easiest conditions to treat are those that never occur. In 2014 all policies must cover services aimed at preventative and chronic care including health screenings, check-ups, monitoring devices and patient education.

Pediatric services, including oral and vision care. Starting in 2014, policies sold through an exchange must include provisions for coverage of healthcare of dependents, including dental and vision care.

For more information on the Affordable Care Act and how it will affect you and your family, contact us at Washington Health Insurance Exchange at 360-464-1622.

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